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Sport, Wettkämpfe und elektive OP während der COVID-19-Pandemie

Sport, Wettkämpfe und elektive OP während der COVID-19-Pandemie

Liebe Mitglieder und Freunde der GOTS,

eigentlich wollten wir Sie Ende Juni in Berlin zum jährlichen Höhepunkt unserer Gesellschaft, dem Jahreskongress begrüßen. Leider macht uns eine Virus-Pandemie in diesem Jahr aber einen Strich durch die Rechnung. Eine sichere Durchführung der Veranstaltung ist unter den derzeitigen Bedingungen und behördlichen Auflagen nicht möglich.

Als Ende letzten Jahres im weit entfernten chinesischen Wuhan aufgrund einer Häufung von Lungenentzündungen ein bis dahin unbekanntes Corona-Virus (SARS-Cov-2) entdeckt wurde, ahnten wir nicht, zu welcher Krise sich dieser Krankheitsausbruch entwickeln würde. Die von diesem neuartigen Erreger hervorgerufene Lungenerkrankung wurde von der Weltgesundheitsorganisation (WHO) schnell mit dem Terminus COVID-19 bezeichnet [9]. Am 11.3.2020 erklärte die WHO den Krankheitsausbruch aufgrund der weltweiten Verbreitung zur Pandemie [9]. SARS-Cov-2 verbreitet sich hauptsächlich durch Tröpfcheninfektion, aber auch auf Oberflächen können die Viren über Stunden bis Tage infektiös bleiben [3]. Mehr als 80% der Fälle verlaufen milde oder symptomlos. Dennoch hat diese Viruserkrankung aufgrund der hohen Reproduktionszahl (R=2-3 ohne Gegenmaßnahmen) die Gesundheitssysteme verschiedener Länder an ihre Grenzen gebracht. Besorgniserregend sind schwere Verläufe mit beidseitigen Lungenentzündungen bis hin zu Lungenversagen und Tod, die jedoch überwiegend bei älteren Patienten beobachtet werden [3].

Um auch die Gesundheitssysteme der deutschsprachigen Länder zu schützen, wurde versucht mit verschiedenen Maßnahmen die exponentielle Ausbreitung des Virus zu verlangsamen [3,4]. Zu den Maßnahmen zählen die Abstandsregeln (1,5 m), die Kontaktbeschränkung oder das Tragen von Masken. Diese Maßnahmen sind mit der Ausführung der meisten Sportarten jedoch unvereinbar. Insbesondere in Kontaktsportarten erschien das Infektionsrisiko zu hoch, um eine sichere Fortführung des Sportbetriebes zu gewährleisten. Folge war, dass nahezu alle großen Ligen unterbrochen oder abgebrochen wurden und auch der Vereinssport im Freizeit- und Breitensportbereich insbesondere für Kontaktsportarten nahezu zum Erliegen kam. Zwischenzeitlich waren in allen Bundesländern auch die öffentlichen Sportanlagen gesperrt. Für den Hochleistungssport gibt es auf Länderebene vereinzelte Ausnahmen, die allerdings immer mit Auflagen versehen sind. Auch Großereignisse wie die Fußballeuropameisterschaft oder die Olympischen Spiele – Hauptthemen unseres geplanten Jahreskongresses in Berlin – fielen der Pandemie zum Opfer. Für die betroffenen Athleten bedeutet die Verschiebung eines Großereignisses wie die Olympischen Spiele Veränderungen in der Trainingsplanung (veränderter WM-Olympia-Zyklus), in der Lebensplanung (z.B. erneute Verschiebung eines Studiums) und finanzielle Unsicherheiten (Wegfall von Sponsoren?) [8]. Auch Fragen hinsichtlich der erneuten Olympiaqualifikation müssen gestellt werden (sind 2021 wirklich die besten Athleten am Start?) [8]. Selbst für das nächste Jahr ist es fraglich, ob die Olympischen Spiele ohne einen wirksamen Impfstoff gegen SARS-CoV-2 stattfinden können. Im Leistungssportbereich müssen ferner Wege gefunden werden, wie die Sportler auch während der Krise sicher trainieren können, um den Trainingszustand aufrecht zu erhalten (Tabelle 1).

Aber auch im Breitensportbereich ist ein kompletter Verzicht auf körperliche Aktivität mit dem Ziel die Ausbreitung von SARS-CoV-2 zu verhindern, falsch. Maßnahmen wie die Verlagerung von Bürotätigkeiten in das „Homeoffice“ schränkt das übliche, meist zu geringe Bewegungspensum weiter ein. Dabei gilt es als erwiesen, dass körperliche Aktivität die Leistung unseres Immunsystems verbessert und kardiovaskuläre Risiken oder das Risiko an Diabetes zu erkranken mindert [5].

Da die Pandemie wahrscheinlich mehrere Monate dauern wird und ggf. auch mit einer zweiten Welle gerechnet werden kann [4], ist es jetzt die Aufgabe der Sportmedizin, für den Leistungssport aber auch für den Breitensport einen bestmöglichen Umgang mit der aktuellen Pandemie zu definieren.

Die bisher ausgesprochenen Empfehlungen umfassen allgemeine Hygienemaßnahmen wie regelmäßiges Händewaschen oder die Händedesinfektion, Training möglichst allein oder in kleinen Gruppen, Training im Freien, Meiden öffentlicher Duschen und Umkleideräume, Training mit den gleichen Personen bis zur Reisewarnung (Tabelle 1) [5]. Beim Training im Freien sollte darauf geachtet werden, dass die Atemwege möglichst warmgehalten werden, da Kälte die Abwehrfunktion der Schleimhäute stört [5]. Allgemeingültige Abstandsregeln (1,5m) können sich in bestimmten Sportarten mit höheren Geschwindigkeiten (z.B. Laufen, Radfahren) jedoch als unbrauchbar erweisen. Hier können mitunter auch weitere Abstände erforderlich sein, um eine Inhalation viral kontaminierter Aerosole zu verhindern. Auch die Veränderung von Startregeln (z.B. im Triathlon) kann diskutiert werden [8]. Der Gebrauch von Masken – unter sportlichen Bedingungen auf dem Spielfeld unpraktisch und vielleicht auch gefährlich – kann bei Fahrten im Mannschaftsbus durchaus sinnvoll sein [4,8]. Eine ausgewogene, vitaminreiche Ernährung kann das Immunsystem unterstützen.

Aber auch auf die Sporttraumatologie hatte die SARS-Cov-2-Pandemie erhebliche Auswirkungen. Es wurde empfohlen, elektive Operationen zu verschieben, um Recourcen für die Bekämpfung der Pandemie zu verlagern und eine Überlastung des Gesundheitssystems zu vermeiden [1,2]. Elektive Operationen dienen der Therapie chronischer Probleme, deren Durchführung verzögert werden kann, ohne den Patienten oder das endgültige Ergebnis wesentlich zu schädigen. Obwohl bei einigen Personen ein Argument für die Notwendigkeit einer Operation aufgrund von Schmerzen oder Funktionsstörungen besteht, ist das entscheidende Prinzip, dass eine Verzögerung der Behandlung das endgültige Ergebnis nicht wesentlich verändert. Solche Operationen umfassen typischerweis den Gelenkersatz, Wirbelsäulenfusionen aber auch Operationen bei chronischen Gelenkerkrankungen (z. B. Rotatorenmanschettenrisse, chronische Instabilitäten des Kniegelenks, Knorpelschäden). Einige dieser Operationen fallen auch in den sporttraumatologischen Bereich.

 

Abbildung 1: Phasen der Pandemie im Hinblick auf das Gesundheitssystem. Die schwarze Linie zeigt eine Entwicklung, in der die Kapazität des Gesundheitssystems (Zahl der Intensivbetten mit Beatmungsmöglichkeit) erreicht wird. Die rote Linie zeigt in etwa die Entwicklung der Pandemie in Deutschland bis Anfang Mai. Damit ist bis zu diesem Zeitpunkt die Kapazität des Gesundheitssystems (Phase 3) nicht erreicht gewesen [4].

 

 

 

 

 

In Anbetracht einer wettkampffreien Zeit stellt sich für viele Athleten nun die Frage, ob evtl. anstehende elektive Operationen nicht gerade jetzt durchgeführt werden können. Um diese Frage auch unter ethischen Gesichtspunkten zu beantworten, darf die Operationsindikation nicht nur auf den Terminus elektiv fixiert werden. Es sollten ferner die von verschiedenen orthopädischen Fachgesellschaften (DGOU, DKG, ESSKA, AAOS) vorgeschlagenen Phasen der Pandemie sowie die Konkurrenz der Operation mit den Recourcen zur Pandemiebekämpfung in Erwägung gezogen werden [4]. Nach den Empfehlungen der Fachgesellschaften wird die Pandemie in verschiedene Phasen eingeteilt (Abb. 1). Danach sollte nur in der Phase 3, in der die Kapazität des Gesundheitssystems erreicht wurde, komplett auf elektive Operationen verzichtet werden [4]. Selbst in Phase zwei können bestimmte elektive Operationen durchgeführt werden, wenn z.B. akute Beschwerden oder Schmerzen oder die fehlende Belastungsfähigkeit der unteren Extremität als Grund vorliegen [2]. Wichtig ist auch zu beachten, ob das entsprechende operative Verfahren mit der Bekämpfung der Pandemie konkurriert (Regional- oder Allgemeinanästhesie, postoperative Intensivüberwachung, stationäre Überwachung notwendig?) und ob der Patient zu einer Riskogruppe gehört [4]. Beide Faktoren treffen auf Sportler meist nicht zu. Die meisten sporttraumatologischen Operationen können in Regionalanästhesie, kurzstationär oder ambulant durchgeführt werden. Eine intensivmedizinische Überwachung entfällt in der Regel. Deutschland hat die Phase 3 der Pandemie bisher nicht erreicht und wird sie vermutlich auch nicht erreichen. Damit kann unter diesen Gesichtspunkten die Phase des „Lockdown“ für die Therapie vieler sportorthopädischer Probleme genutzt werden. Dies gilt insbesondere vor dem Gesichtspunkt, dass die Stornierung vieler Wettkämpfe eine verletzungsgerechte Rehabilitation ohne Zeitdruck ermöglicht.

Ich möchte dieses Editorial mit einem Ausflug in die sportorthopädische Präventionsforschung abschließen. In den deutschsprachigen Ländern konnte durch verschiedene Präventionsmaßnahmen verhindert werden, dass die Kapazitäten der Gesundheitssyteme überschritten wurden. In Deutschland blieben 20–30% der geschaffenen Intensivkapazitäten ungenutzt (o.g. Ressourcenumverteilung). Gleichzeitig konnte die Pandemiekurve durch verschiedene Maßnahmen abgeflacht werden. Dabei wurden auch freiheitliche Grundrechte inklusive der freien Sportausübung außer Kraft gesetzt. Diese Maßnahmen wurden aufgrund epidemiolgischer Daten erlassen. Nun wird es wichtig sein, diese Maßnahmen wissenschaftlich auf ihre Effektivität und Notwendigkeit zu überprüfen, wie es auch in der sporttraumatologischen Präventionsforschung üblich ist (Abb. 2). Abbildung 2 zeigt den Präventionszyklus nach van Mechelen [6]. Zumindest geben neuere Antikörperstudien Grund zur Hoffnung [7]. Diese zeigen, dass die Mortalitätsrate von COVID 19 weit unter 1% (Heinberg 0,37% und Santa Clara 0,2%) liegt und sich damit weit unter der Mortalitätsrate der ersten Coronavirus Epidemie im Jahre 2003 (SARS 1) befindet (10% Mortalitätsrate) [7].

Abbildung 2: Kreislauf der Präventionsforschung nach van Mechelen.

 

 

 

 

 

 

 

 

 

 

 

 

 

Ich hoffe, dass wir aus dieser Krise lernen und positive Aspekte (Telemedizin, Webinarfortbildungen, Digitalisierung etc.) in eine neue Zukunft retten. Das Organisationsteam des Kongresses und der GOTS-Vorstand sind dabei, Alternativszenarien zu entwickeln, um die wissenschaftlichen Leistungen insbesondere der jüngeren Kongressteilnehmer und des GOTS-Nachwuches trotz der Kongressabsage wertzuschätzen. Schließlich gibt es nichts frustrierenderes, als eine wissenschaftliche Arbeit, in die man tage-, wochen oder monatelang Zeit investiert hat, nicht vorstellen zu dürfen. Ein Großteil der Arbeiten wird auf den GOTS-Kongress in Basel 2021 verlegt werden. Genaueres werden wir Ihnen in einigen Wochen mitteilen. Auch werden wir versuchen, Ihnen einen Teil der Inhalte des Kongresses in Form von Webinaren anzubieten. Ich hoffe, dass Sie dieses Angebot nutzen werden und dass wir uns alle bald wieder auf einem GOTS-Kongress sehen können.

 

Im Namen des GOTS Vorstandes,

Prof. Dr. Wolf Petersen, Kongresspräsident Berlin 2020

 

Ratschläge zum Verhalten von Sportlern während der SARS-CoV-2-Pandemie:

Maßnahmen
regelmäßiges Händewaschen oder die Händedesinfektion
ein Ergometer- und Krafttraining zu Hause
Training in kleinen Gruppen (bis max. 5 Sportler*innen) im nicht-öffentlichen Raum
Training mit den gleichen Personen
Training im Freien
Abstandregeln beachten (beim Laufen und Radfahren höhere Abstände zum Vordermann sinnvoll)
Meiden öffentlicher Duschen und Umkleideräume
Möglichst keine Reisen, ggf. individuelle Anreise
Mundschutz bei Reisen, z.B. im Mannschaftsbus

 

Literatur

 

  1. American College of Surgeons Clinical Issues and Guidance. https://www.facs.org/covid-19/clinical-guidance. Zugegriffen: 08. April 2020
  2. Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (2020) Empfehlungen für den Umgang mit Unfallverletzten und OP-Indikationen. https://dgou.de/news/news/detailansicht/artikel/empfehlungen-fuer-den-umgang-mit-unfallverletzten-und-op-indikationen-1/. Zugegriffen: 08. April 2020
  3. Robert Koch-Institut R (2020) SARS-CoV-2 Steckbrief zur Coronavirus-Krankheit-2019 (COVID-19). https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Steckbrief.html#doc13776792bodyText2. Zugegriffen: 05. April 2020
  4. Petersen W, Bierke S, Karpinski K, Häner M. Coronavirus: Pandemie und ihre Auswirkungen auf O und U: Operationen, Risiken und Prävention. Kniejournal: https://www.springermedizin.de/covid-19/coronavirus-pandemie-und-ihre-auswirkungen-auf-orthopaedie-und-u/17911282
  5. Steinacker JM, Bloch W, Halle M, Mayer F, Meyer T, Hirschmüller A, Röcker K, Nieß A, Scharhag J, Reinsberger C , Scherr J, Niebauer J, Wolfarth B und Sports Medicine Commission der FISA. Merkblatt: Gesundheitssituation für Sportler durch die aktuelle Coronavirus-Pandemie (SARS- CoV-2 / COVID-19). Dtsch Z Sportmed. 2020; 71: 85-86.
  6. Van Mechelen, W., Hlobil, H. & Kemper, H. C. (1992). Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports medicine (Auckland, N.Z.), 14 (2), 82-99. doi:10.2165/00007256-199214020-00002
  7. Vogel G. Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable: https://www.sciencemag.org/news/2020/04/antibody-surveys-suggesting-vast-undercount-coronavirus-infections-may-be-unreliable
  8. Wolfarth B, Häner M, Grim C, Krutsch W, Petersen W. Sport und Corona. https://www.congress-live.de/sport-und-corona.html
  9. Weltgesundheitsorganisation (2020) Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). https://www.who.int/news-room/detail/30-01-2020-statement-

 

 

 

 

 

 

 

 

 

 

 

 

 

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